Provider Demographics
NPI:1639230873
Name:COOK, GREGORY D (ACSW, CSW)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:COOK
Suffix:
Gender:M
Credentials:ACSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 COMMONS PKWY
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3987
Mailing Address - Country:US
Mailing Address - Phone:517-349-6370
Mailing Address - Fax:517-349-8212
Practice Address - Street 1:2165 COMMONS PKWY
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3987
Practice Address - Country:US
Practice Address - Phone:517-349-6370
Practice Address - Fax:517-349-8212
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010068381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0890747Medicare ID - Type Unspecified